DPO - Designated Provider Organization

Not all health plans work the same way. This website will explain how the Designated Provider Organization (DPO) plan works, so be sure to read through it carefully to understand your plan.

We suggest that after you read through this website, you visit mytuftshealthplan.com, our secure members-only site, to learn the details of the specific plan your employer has chosen for you. And be sure to read your Benefit Document, available at mytuftshealthplan.com, to see a complete list of your specific plan’s covered and non-covered benefits.

Knowledge is power, and knowing how your plan works will give you the power to plan for and control your out-of-pocket costs.

Three tiers, one of which you’re already very familiar with.

Tufts Health Plan has created a comprehensive network of primary care providers, specialists and hospitals. Every doctor and every hospital in that network has been carefully evaluated based on many criteria. As part of our National Committee for Quality Assurance (NCQA) accreditation and our own quality standards, we are committed to contracting only with high-performing providers. Rest assured, every provider and hospital in the Tufts Health Plan network meets our standard for quality of care.

One way health care providers differ, though, is in their cost. Not all doctors and hospitals charge the same costs. So we’ve factored in cost-efficiency in our evaluation, and have separated the providers into three levels, or tiers.

What makes the DPO plan so unique and so appealing is that Tufts Health Plan will work with provider organizations to create a low-cost tier composed of the provider’s own affiliated resources. In the DPO plan, this is Tier 1. Only provider organizations are able to offer their employees the DPO plan. What that means, in other words, is that if you are being offered a DPO plan, you work for a large provider network, and the lowest cost tier is composed of your very own doctors, hospitals and specialists.

Cost-Effective and Convenient

Choosing to visit the providers in your DPO tier is extremely cost-efficient. And since you can schedule a doctor visit for when it’s easiest for you, lunch hour for example, using your DPO tier is also extremely convenient.

You don’t have to only visit your physician at your medical center, either. If you prefer to visit a physician office that’s nearer your home, you can do that. If your family wants to visit an office that’s near home without ever coming to your medical center, they can do that, too.

A Word About Privacy

We’d like to assure you that patient confidentiality is of the utmost concern to us. The same privacy guidelines that every physician everywhere is required to follow also apply here. Rest assured, the doctor-patient relationship in the DPO tier is no different than any other doctor-patient relationship.

Can You Go Outside Your Tier?

Yes, you’re free to visit any provider you want. For example, you may want to see a certain specialist that isn’t affiliated with your medical center. Again, though, your DPO tier will be the most cost-effective tier, so if you want to visit a doctor or hospital in Tier 2 or Tier 3, the out-of-pocket cost will be higher.

Can you Mix and Match?

To an extent. First, it’s important to know that for any given year, a doctor of a certain tier is always associated with a hospital of the same Tier. That’s generally the primary hospital system with which the provider is affiliated. Again, it has to do with cost, not quality.

So let’s say your primary care physician is Tier 1 and you need knee surgery. Your doctor will most likely refer you to a specialist and hospital that are Tier 1. But let’s say you’re interested in a Tier 3 specialist. If so, you can choose that doctor, but your out-of-pocket costs will be higher.

Another scenario might be that your spouse has a long-standing relationship with a doctor, but the doctor is Tier 3. Your spouse prefers to continue seeing that doctor, knowing your out-of-pocket costs will be higher. But you prefer to use the doctors in your DPO tier, Tier 1. In this scenario, it’s perfectly okay to mix and match, and give everyone their choice.

In a serious emergency situation, though, you don’t have to think about Tier 1 this or Tier 2 that. You just call 9-1-1 if the situation warrants it, or drive to the nearest emergency room if that’s appropriate. Under the DPO plan, the emergency room copay is always equal to the Tier 1 emergency room copay for both the doctor and the hospital.

Remember, if you have any questions at all, we’re here for you.

The goal of the DPO plan is to enable employers to offer high-quality health care coverage to their valuable employees (you). One of the ways the DPO plan helps accomplish this is by incorporating a fee structure that requires some cost-sharing on your part.

This cost-sharing is primarily in the form of two components: the copay and the deductible.

The Copay

A copay is a fee that you pay as partial payment for certain services. For instance, a visit to the doctor’s office often requires a copay. That means you pay, for example, $20 out-of-pocket as your copay. If a copay is required for the type of medical service you want, you are responsible for the copay.

You can find out exactly what your specific plan covers by reading your Benefit Document or accessing your secure member account at mytuftshealthplan.com.

The Deductible

Depending on the specifics of your plan, you may be subject to a deductible.

If your specific plan has a deductible, the deductible is the amount you must pay before your insurance kicks in. We’re speaking here only of the services that are subject to a deductible. Not everything you go to the doctor for is subject to the deductible. In other words, there are some things you can go to the doctor for that are covered right away, without your having to meet your deductible. These are generally preventive services and office visits, but they’re spelled out in greater detail in the second section of this Member Kit.

The deductible for your specific plan can vary. The amount is chosen by your employer, based on how much the entire plan costs them. We work closely with your employer to provide the best possible plan at the best possible cost for both employer and employee.

Here’s an example of how the deductible works. Let’s say your plan has a $1000 family deductible and a $500 individual deductible. You’re working in the yard, you have an accident, and you have to make a trip to the emergency room. Your maximum responsibility as an individual would be $500, not the entire $1000. Let’s say you have another accident in the same plan year. Your individual deductible of $500 has already been met, so you’re not responsible for any deductible amount.

Now let’s say your spouse needs surgery. Your family is now responsible for the remaining $500 deductible, since it’s a different individual. But now your total amount paid toward your $1000 deductible has been met. The next time anyone in your family needs medical services that are subject to the deductible, you don’t have to worry about the deductible. The deductible for the plan year has been met.

A Word About Coinsurance

Your plan may also have a coinsurance component. Coinsurance applies primarily to durable medical equipment (such as a wheelchair or crutches), hearing aids, low-protein foods and prosthetics. If you require any of those items, and if your specific plan has a coinsurance component, you would share a percentage of the cost.

In some cases, coinsurance may also apply to other items. You can find the specifics of your plan, including the exact amount of any potential coinsurance, by reading your Benefit Document or by visiting mytuftshealthplan.com.

The Out-of-Pocket Maximum

You’ll be glad to know there’s a limit on what you may possibly pay during a calendar year. It’s called an Out-of-Pocket maximum. The Out-of-Pocket maximum is the most you can pay during your coverage period (typically one year) for your share of the cost of covered services.